BREINING INSTITUTE 8894 GREENBACK LANE ORANGEVALE, CALIFORNIA USA TELEPHONE (916)

BREINING INSTITUTE 8894 GREENBACK LANE • ORANGEVALE, CALIFORNIA USA 95662-4019 • TELEPHONE (916) 987-2007 Advanced Credential for the Addiction Profe...
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BREINING INSTITUTE 8894 GREENBACK LANE • ORANGEVALE, CALIFORNIA USA 95662-4019 • TELEPHONE (916) 987-2007

Advanced Credential for the Addiction Professional

CLINICAL SUPERVISOR CREDENTIAL (CSC) The Clinical Supervisor Credential (CSC) is available to individuals with an underlying addiction professional license or certification from an accredited, State-approved or nationally-recognized licensure or certifying agency, when they meet the CSC standards and document their eligibility. There are no application fees to be granted the CSC, although you will need to pass the multiple-choice Private-practice / Clinical Supervisor (PCS) Examination, which is administered daily at over 500 test centers located throughout the United States and Canada.

ELIGIBILITY CURRENT CERTIFICATION OR LICENSE Must hold current addiction professional license or certification from an accredited, State-approved or nationally-recognized licensure or certifying agency EDUCATION 40 hours of documented education in courses related to clinical supervisor competencies EXPERIENCE Three years full time or 6,000 hours clinical experience in AOD counseling One year full time (or 2,000 hours) as an AOD supervisor (may be included in general AOD experience) EXAMINATION Must receive a passing score on the Breining Institute multiple-choice PCS exam PROFESSIONAL REFERENCES One reference from a supervisor of your work, or from a colleague in the same field; AND Two references from professionals in the field of addictions who know of your work _______________________________________________ ACCEPTABLE SUBSTITUTES for EXPERIENCE REQUIREMENT The minimum clinical and/or supervisor experience required is 2,000 hours (or 1 year) Acceptable substitutes for up to 4,000 hours of experience may include a degree or teaching A degree in addiction studies or the healing arts may substitute as follows: AA or AS degree may substitute for 2,000 hours of clinical experience BA or BS, MA or MS, or Doctorate degree may substitute for 4,000 hours of clinical experience Experience teaching a course or courses within an AOD program: Ten hours of Clinical Experience credited for each One hour of class taught _______________________________________________ RENEWAL REQUIREMENT Every two years Six (6) hours of Continuing Education in Clinical Supervision

www.breining.edu Breining Institute is a private college that has been dedicated to higher education, training, testing and certification for addiction professionals since 1986.

APPLICATION for the

CLINICAL SUPERVISOR CREDENTIAL (CSC) Breining Institute • 8894 Greenback Lane • Orangevale, California USA 95662-4019 • Telephone (916) 987-2007 • Facsimile (916) 987-8823 SECTION 1. Please type or print all of your information clearly. Incomplete applications will not be processed.

First Name

Middle Name

Last Name

Address (Number, Street, Apartment or Suite Number)

City

State (or Province)

USA Zip Code

Country (other than USA)

Country Code

Primary Telephone Number (including Area Code)

Secondary Telephone Number (including Area Code)

Pager Number (including Area Code)

Facsimile Number (including Area Code)

E-mail Address

Web Site Address SECTION 2. This information is for verification purposes. Please print your information clearly.

Social Security Number (last 4 numbers only)

Date of Birth (Month-Day-Year)

Male

Female

SECTION 3. REQUIRED DOCUMENTATION. EDUCATION q Documentation of 40 hours of courses related to clinical supervisor competencies. EXPERIENCE q Clinical Experience documentation: Use one “Section 6” page for each employer or volunteer agency. q Clinical Experience Substitute documentation, if applicable: Use one “Section 7” page for each educational institution. REFERENCES q Three Professional References: Use one “Section 8” page for each reference. Be sure to include one supervisor and two other references. CODE OF ETHICS q Signed Code of Ethics: Sign and date the Code of Ethics located at the “Section 9” page. PHOTOGRAPH q Current photograph, with your full name written on back. CURRENT LICENSE OR CERTIFICATE q Copy of current addiction professional license or certificate must accompany application. PCS EXAM SCORE SHEET q Copy of Breining Institute Private-practice / Clinical Supervisor (PCS) Exam Score Sheet, which documents that you passed the PCS exam. CLINICAL SUPERVISOR CREDENTIAL (CSC) APPLICATION – Page 2

2011 © Breining Institute (1110261824)

SECTION 4. 40 hours in COURSES RELATED TO CLINICAL SUPERVISOR COMPETENCIES You are required to have completed 40 hours of documented education related to the knowledge and skills necessary to competently carry out the responsibilities of a clinical supervisor. Those include courses related to the performance domains identified within the Technical Assistance Publication (TAP) Series 21-A: Competencies for Substance Abuse Treatment Clinical Supervisors (otherwise know as the “TAP 21-A Supervisor Competencies”). Please identify which courses you have taken below that apply to the study areas indicated. The courses may have been taken from approved or accredited institutions of higher education, and the coursework should have included instruction related to the following TAP 21-A Performance Domains: of 1) Counselor Development; 2) Professional and Ethical Standards; 3) Program Development and Quality Assurance; 4) Performance Evaluation; and 5) Administration. Provide certificates of completion or transcripts which verify the completion of the topics identified above, and list those institutions and courses below: Name of Institution

Course(s)

Hours or Units

Date completed

_______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________

SECTION 5. DEGREE If applicable, please identify the degree that you received in the healing arts or related field, as well as the institution from which you obtained the degree. You will also need to provide a copy of or original transcripts of the degree to Breining Institute, with this application. Name of Institution

Degree(s)

Units

Date completed

_______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________ _______________________________________ _______________________________________ _______________ _____________

CLINICAL SUPERVISOR CREDENTIAL (CSC) APPLICATION – Page 3

2011 © Breining Institute (1110261824)

SECTION 6. CLINICAL EXPERIENCE (please duplicate this page for each different employer or volunteer agency) • You will need to document 6,000 hours (three years) of clinical experience, AND • You will need to document 2,000 hours (one year) of experience as an AOD supervisor (may be included in total clinical experience). • You may substitute or supplement your clinical experience with a degree or experience teaching in an AOD program (see Section 7).

Applicant Name

Your Title or Position with the Agency / Organization

Name of Supervisor

Title / Position of Supervisor

Agency / Organization

Address (Number, Street, Apartment or Suite Number)

City

State (or Province)

USA Zip Code

Country (other than USA)

Country Code

Agency’s Main Telephone Number (including Area Code)

Supervisor’s Direct Telephone Number (including Area Code)

E-mail Address

Web Site Address Dates and hours associated with AOD and/or supervisor activities within this organization (full time equals 2,000 hours per year): From:

To:

Total Hours:

M o nth  /  Y ear

M o nth  /  Y ear

A ppro ximate

Job Description: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Attestation of Agency / Organization Representative: I attest the above information is true and correct.

Printed name of Agency Representative

CLINICAL SUPERVISOR CREDENTIAL (CSC) APPLICATION – Page 4

Signature

Date

2011 © Breining Institute (1110261824)

SECTION 7. CLINICAL EXPERIENCE SUBSTITUTE (please duplicate this page for each different educational institution) Complete this section if you are seeking to substitute or supplement the Clinical Experience requirement (identified in Section 6) with your experience teaching a course or courses within the healing arts or related field at an approved or accredited institution of higher learning. You may substitute ten (10) hours of Clinical Experience for each hour of class that you have taught. (PLEASE NOTE: MUST HAVE A MINIMUM OF 2,000 HOURS – or 1 YEAR – OF ACTUAL CLINICAL AND / OR SUPERVISOR EXPERIENCE.)

Applicant Name

Your Title or Position at Educational Institution

Name of Supervisor or Department Head

Title / Position of Supervisor or Department Head

Educational Institution

Address (Number, Street, Apartment or Suite Number)

City

State (or Province)

USA Zip Code

Country (other than USA)

Country Code

Institution’s Main Telephone Number (including Area Code)

Supervisor’s Direct Telephone Number (including Area Code)

E-mail Address

Web Site Address Course Name(s) dates, and hours taught at this institution:

Course Title(s)

Dates that course(s) were taught From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

From:

To:

Hours / class

Total classes

Total hours

Attestation of Educational Institution Representative: I attest the above information is true and correct.

Printed name of Institution Representative CLINICAL SUPERVISOR CREDENTIAL (CSC) APPLICATION – Page 5

Signature

Date 2011 © Breining Institute (1110261824)

SECTION 8. PROFESSIONAL REFERENCES (please duplicate this page for each reference) A total of three references from professionals in the field of addictions who can attest to your proficiency in the field: • One reference must be from a supervisor of your work, or from a colleague in the healing arts field; AND • Two references must be from professionals in the general field of addictions, who know of your work in the field.

Applicant Name

Name of Professional Reference

Relationship of Professional Reference to Applicant (Supervisor, Colleague or Addiction Professional)

Title / Position of Reference

Agency / Organization

Address (Number, Street, Apartment or Suite Number)

City

State (or Province)

USA Zip Code

Country (other than USA)

Country Code

Agency’s Main Telephone Number (including Area Code)

Reference’s Direct Telephone Number (including Area Code)

E-mail Address

Web Site Address Please explain why you believe that the Applicant should be awarded the Clinical Supervisor Credential (CSC): __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________

Printed name of Professional Reference

CLINICAL SUPERVISOR CREDENTIAL (CSC) APPLICATION – Page 6

Signature

Date

2011 © Breining Institute (1110261824)

SECTION 9. CODE OF ETHICS You are required to maintain compliance with the Code of Ethics for CSC Professionals. Sign this Code of Ethics at the space provided below.

Clinical Supervisor Credential (CSC)

CODE OF ETHICS

As a Clinical Supervisor Credential (CSC) professional, I will comply with this Code of Ethics and do affirm: q That my primary goal is recovery for the client and the client’s family, through conducting my role as a supervisor in a professional and caring manner. q That I have a total commitment to provide the highest quality of supervision to those whom I am committed to providing supervision. That I shall not provide services beyond the terms and conditions of my professional certifications and/or licenses. q That I shall evidence a genuine interest in all of the individuals that are supervised by me, and do hereby dedicate myself to the best interest of my agency and supervisees, and to help them help themselves. q That I shall maintain at all times an objective, professional relationship with all of my supervisees. q That I shall adhere to the Rule of Confidentiality with regard to all records, material and knowledge concerning my client, and shall protect his/her rights to confidentiality in accord with Code of Federal Regulations, Title 42 sections 2.1 through 2.67(1) and any other applicable regulations. q That I shall cooperate with complaint investigation and supply information requested during such complaint investigations, subject to the confidentiality provisions cited above. q That I shall not in any way discriminate between clients or fellow professionals on the basis of race, religion, age, gender, disability, national ancestry, sexual orientation or economic condition. q That I shall respect the rights and views of my fellow counselors and other addiction professionals. I will not verbally, physically or sexually harass, threaten, or abuse any program participant, patient, client or fellow addiction professional. q That I shall maintain respect for institutional policies and management within agencies, and will take the initiative toward improvement of such policies and management when it will better serve the interests of my supervisees. q That I have a continuing commitment to assess my own personal strengths, limitations, biases and effectiveness. q That I shall continuously strive for self-improvement and professional growth through further education and training. q That I have an individual responsibility for my own conduct in all areas, including, but not limited to, the use of mood-altering drugs. I shall not provide supervision, counseling or education services while under the influence of any amount of alcohol or illicit drugs (not including drugs or medication prescribed by a physician or other person authorized to prescribe drugs, used in the dosage and frequency prescribed; nor including over-the-counter medications used in the dosage and frequency described on the box, bottle or package insert). q That I have an individual responsibility for myself in regard to sexual conduct and/or contact with fellow counselors, supervisors, supervisees, and clients, and shall not engage in sexual conduct with current program participants, patients or clients. q These things I pledge to my professional peers and to my supervisees. q I hereby pledge to comply with this Code of Ethics, as well as to comply with a consistent code of conduct that may be applicable to a recovery or treatment program with which I may be affiliated. Printed name of CSC appllicant

Signature

CLINICAL SUPERVISOR CREDENTIAL (CSC) APPLICATION – Page 7

Date

2011 © Breining Institute (1110261824)

SECTION 10. PHOTOGRAPH Include a recent photograph of yourself. This photo will be used by Breining Institute to identify you. Write your full name on the back of the photo, which may be any size between 1” x 2” and 8” x 10”. We will keep your photo in your file, and it will not be returned. SECTION 11. PREVIOUS CERTIFICATION STATEMENT Have you had a prior certification or licensure as an alcohol or drug counselor revoked? q YES q NO If yes, please explain: ________________________________________________________________________________________________ SECTION 12. DOCUMENTATION. Please check all that are applicable to your Application: Currently licensed or certified professional q I attest that I am a currently licensed and/or certified addiction professional:

Expiration date of current license or certificate (Month – Day – Year)

Title of license or certificate r License or certification number

Name of licensing or certifying agency

Web site address of licensing or certifying agency Documentation included with this Application (please check all that apply) q Documentation of 40 hours in courses related to clinical supervisor competencies (certificates of completion, transcripts, etc.). q If applicable, documentation of Degree (copy of or official transcripts are acceptable). q Clinical Experience documentation: Use one “Section 6” page for each employer or volunteer agency. q Clinical Experience Substitute documentation, if applicable: Use one “Section 7” page for each educational institution. q Three Professional References: Use one “Section 8” page for each reference. Be sure to include one supervisor and two other references. q Signed Code of Ethics: Sign and date the Code of Ethics located at the “Section 9” page. q Current photograph, with your full name written on back. q Copy of current addiction professional license or certificate. q Copy of Breining Institute “Private-practice / Clinical Supervisor (PCS) Exam” Score Report.

ATTESTATION OF INFORMATION AND DOCUMENTATION The undersigned Applicant declares that the information provided in the Application and within the supporting documentation is true and authentic. I intend to comply with the provisions of the CSC Code of Ethics. The Applicant understands that if at any time it is shown that the information or documentation provided is not true or is misrepresented, any fees which have been paid will be forfeited by Applicant, and certification as a CSC may be revoked. ___________________________________________________________________________ Signature

_____________________________ Date

Return this completed Application and supporting Documentation by postal mail, fax or e-mail to:

Breining Institute 8894 Greenback Lane Orangevale, California USA 95662-4019 Fax: 916-987-8823 E-mail: [email protected] Questions? Please call us at 916-987-2007

CLINICAL SUPERVISOR CREDENTIAL (CSC) APPLICATION – Page 8

2011 © Breining Institute (1110261824)